Published online Nov 21, 2017. doi: 10.3748/wjg.v23.i43.7746
Peer-review started: July 24, 2017
First decision: August 30, 2017
Revised: September 12, 2017
Accepted: October 28, 2017
Article in press: October 28, 2017
Published online: November 21, 2017
Tissue glue has been widely used in endoscopic gastric variceal obturation (EGVO). Although EGVO is usually safe and effective, a series of complications can occur. Post-endoscopic treatment complications have been widely reported and discussed, but there is little in-depth discussion on procedure-related complications. The complications associated with tissue glue that occur during gastric variceal obturation were retrospectively evaluated in the current study.
Post-endoscopic treatment complications of EGVO such as abdominal pain, pyrexia, organ embolization and local ulceration have been widely reported and discussed, but the incidence of procedure-related complications was calculated in only some studies and was not thoroughly analyzed. Most of the procedure-related complications were only described as case reports. In the current study, the authors focused on procedure-related complications, evaluated their incidence, analyzed the reasons and discuss the solutions. The authors hope that the cases described in the current study can provide some reference for others.
The main objectives of the current study was to evaluate four procedure-related complications of EGVO, including sticking of the needle to the varix, glue adhesion to the endoscope resulting in difficulty withdrawing the endoscope, blockage of the catheter during the injection, and more seriously, sticking of the ligation device to the esophageal varices in the subsequent endoscopic variceal ligation. Investigation of the incidence, reasons and solutions of these complications is expected to help the endoscopists especially those in training to avoid some troubles.
Six hundred and twenty-eight EGVO procedures (case-times) with tissue glue were performed in 519 patients in the Department of Endoscopy of the Third Affiliated Hospital of Sun Yat-Sen University from January 2011 to December 2016. The tissue glue used in EGVO was N-butyl-2-cyanoacrylate (NBC). The endoscopic reports and medical records of all patients were collected. The clinical data of patients and procedure-related complications of EGVO were retrospectively analyzed.
In the 519 patients, HBV cirrhosis was the most cause of gastric varices (75.5%) and the most common type of gastric varices was GOV1 + GOV2 (58.6%). Most of the patients had a liver function of Child-Pugh A (37.6%) or Child-Pugh B (44.5%). Detailed injection methods were written by endoscopists in 473 out of 628 EVGO procedures, including 263 procedures that were performed using the classical “sandwich” injection with lipiodol-diluted NBC, 159 procedures that were performed with undiluted NBC, and the remaining 51 procedures that were performed using other modified “sandwich” injections. In the 628 EGVO procedures, sticking of the needle to the varix occurred in 9 cases (1.43%), including 1 case that used lipiodol-diluted NBC and 8 cases that used undiluted NBC (P = 0.000). There was no statistical difference of the complication among the patients with liver function of Child-Pugh A, B and C (P = 0.629). The needle was successfully withdrawn in 8 cases. Large spurt bleeding occurred in one case, and hemostasis was achieved by two other injections of undiluted glue. The injection catheter became blocked in 17 cases (2.71%) just during the injection, and 4 cases were complicated with the needle sticking to the varix. Large glue adhesion to the endoscope resulted in difficulty withdrawing the endoscope in 1 case. Bleeding from multiple sites was observed in the esophagus and gastric cardia after the endoscope was withdrawn. Hemostasis was achieved by 1% aethoxysklerol injection and intravenous somatostatin. The ligation device stuck to the varices in two cases during the subsequent endoscopic variceal ligation (EVL). In one case, the ligation device was successfully separated from the esophageal varix after all bands were released. In another case, a laceration of the vein and massive bleeding were observed. The bleeding ceased after 1% aethoxysklerol injection.
The findings of this study verified that procedure-related complications were rare but sometimes were extremely dangerous. There is currently no standard operating procedure for addressing these complications. To avoid procedure-related complications, comprehensive preparation, careful and skillful operation, and smooth assistance are very important.
Although EGVO with tissue glue is usually safe and effective, a series of complications can occur during the procedure. Some factors might influence the occurrence of the complications and their outcomes, including Child-Pugh Class, type of gastric varices (GOV1, GOV2, IGV1 and IGV2), platelets, INR, volume of tissue glue using during EGVO, and diameter of the injection needle. These factors were not fully investigated and discussed in the current retrospective study. A well designed prospective study with a large sample is expected to solve that problem.